In November 2011, the Armstrong Institute for Patient Safety and Quality at Baltimore-based Johns Hopkins Medicine received $10 million from the Agency for Healthcare Research and Quality to reduce surgical site infections and other complications from colon surgery. The project will be modeled in part by the work of Peter J. Pronovost, MD, PhD, director of the Armstrong Institute, who developed a checklist that helped significantly reduce central line-associated bloodstream infections.
Dr. Pronovost explains how this current project is taking a new approach to quality improvement.
Q: What strategies will you use to reduce SSIs?
Dr. Pronovost: The program is not just for SSIs, but other types of complications such as deep venous thrombosis, pulmonary complications and readmissions. We are focusing on all four of those. We are starting with colon surgery and will later expand to other types of surgery.
The approach that we're using is the concept of a clinical community. That concept is that amongst professional groups, quality improvement programs that are developed with rather than over clinicians are more likely to be wise, effective and locally implemented given the local context. Too often quality improvement programs are top down and they do not get implemented because clinicians had no role in creating it. It is really the concept of the community trusting clinicians to know what the risks are and empowering them to improve their own local risks. The community is supported by a technical core that provides support for measurement and improvement methods.
Within the community, there are three legs: measurement and feedback of performance data, implementation of best practices to prevent harm — for example, using a checklist or some intervention — and third, and perhaps most challenging, to improve culture and teamwork.
Q: How are the clinical communities organized?
PP: Communities are organized around states, health systems or interested hospitals. In this program, we partner with state hospital associations and the American College of Surgeons and then invite hospitals within [those associations] to participate. We have a series of conference calls or webinars to get out didactic material to clinicians. We then bring them all together for a face-to-face meeting for a day. It is very interactive; we talk about what we need to do to reduce harm, what barriers they think they're going to face, what successes others have had and what the training, measurement and outcome data will be. Then teams go back to the hospital and we have a series of biweekly or monthly coaching calls that involve the team from each hospital and a coach from the technical core — essentially it is peer coaching. We talk about what they're struggling with and they go back to implement changes.
Q: Why is the clinical community approach so important?
PP: If you look at quality improvement right now, most clinicians and nurses believe quality improvement is done to them rather than something they do. Most quality efforts are top down. But in part, the regulators have a strong voice because clinicians haven't stepped up to lead. In this work, when clinicians do it, it's much more effective. It's much more joyful because they really feel good about their work. It's going to take physician leadership.
Q: How can hospitals encourage physician leadership?
PP: One, hospitals can give physicians defined roles as quality and safety leaders in their institutions and ensure they have the time and skills to lead those roles. The average medical school doesn't prepare physicians with the tools they need to lead quality improvement efforts. For the most part physicians need formal training in the safety sciences. This should include training in designing, implementing and evaluating interventions; identifying and mitigating risks; improving teamwork and safety culture; and leading change. We are developing a safety certificate to provide this training for clinical leaders. Yet to really understand measurement and evaluation, physicians will likely need a public health degree. When the physicians have the right skills, the hospital can provide financial support for the time they devote to lead quality improvement efforts. If doctors spend their time doing quality, they're not generating income. It costs physicians money, yet it has enormous value. Without physician leadership, quality improvement efforts are unlikely to succeed. We need the hospital to provide support for clinicians, agree on the results they should achieve and hold them accountable.
Q: How do you plan to achieve a cultural change?
PP: We have this program called the comprehensive unit-based safety program, which is a unit-based team that tries to educate clinicians on the science of safety and the value of teamwork, provide tools to practice teamwork in a safe space and talk with peer leaders about role modeling good teamwork and culture change and through that, change the social norms.
The biggest culture change in all other work to reduce harms is whether the clinicians really believe that it's their job to reduce these harms and that they're able to do so. So often doctors say, "These infections just happen, there's nothing we can do about it. We operate on very, very sick patients." If they say that, it becomes a self-fulfilling prophecy. It is a big change to say, "These infections aren't inevitable, they're largely preventable, and I have the ability to help change that." When doctors believe that, they solve the rest of the problems. A large part of this program is to help physicians believe that harm is largely preventable and they can change their system to improve.
Q: How do you convince clinicians that they can make a difference in the rate of infections?
PP: We show them their own data about how often they use evidence-based practices, and work to make sure we are 100 percent on these. We ask them to tell stories on patients who have been harmed. Such stories do not quantify our improvement, but they are powerful in engaging clinicians about why this is so important.
Q: How will you recruit hospitals to participate in the project?
PP: We are going to recruit in two ways. The initial hospitals we are going to work with are hospitals that are already part of [the American College of Surgeons' National Surgical Quality Improvement Program] because we otherwise would not have baseline data to show things actually got better. The second year will be non-NSQIP hospitals. For both efforts, we are collaborating with the newly created Hospital Engagement Networks funded by CMS. We will present this program to HENS and send out invitations to state hospital association members. As you can imagine, those two ways will target different groups: The American College of Surgeons is more likely to get surgeons, and the HENS and state hospital association are more likely to get hospital executives.
What we've found is if you only get clinician buy-in, you often don't get enough support to do the work. On the other hand, if you only get executive buy-in, the program is rarely implemented at the bedside. There are so many examples where an executive signs up for a program and it is not implemented because clinicians often don't even know about it. You need to get both executive support and connect with practicing clinicians. One of the unique things about this program is that it's not either-or but about bringing those groups together. We try to bring together all stakeholders, hospital executives, clinicians, quality leaders, infection prevention staff and others. It takes a village to improve quality. We really have to work with everyone together to do this.
Q: What is your projected timeline for the initiative?
PP: The first year we will try 10 hospitals in 10 states. Then we will expand to the rest of the hospitals — importantly, the hospitals not originally doing the American College of Surgeons' NSQIP program. Probably in [six] months, we will begin implementing interventions. This study was funded prior to the launch of the HENS program by CMS. As such we will work closely with those efforts. We need to be sure that hospitals are implementing state-of-the-art safety programs that include valid measurement. What we've seen in other work, [such as with] pneumonia, is within three months we cut infections in half and by six months it is nearly eliminated. We think we can see, once we design the program over the next [six] months, that kind of rapid improvement.
Q: Will you implement a checklist as part of an intervention?
PP: We will certainly be using checklists. One of the things we realize is one of the main reasons patients don't get evidence-based practices is the ambiguity of who is supposed to do what, where, when and how. A checklist could be good to clarify behaviorally what to do. Even if people know, sometimes there are barriers, [such as] equipment. We will also identify local barriers to compliance with the checklist and then strategize to overcome those barriers. Simply handing clinicians a checklist will not likely be effective.
Q: How can equipment be a barrier to implementing evidence-based medicine?
PP: For example, in blood-stream infection work, we made a checklist, and the checklist required that doctors wear a cap and gown and mask. It sounds simple, but when we looked, that equipment was stored in eight different places. Doctors had to go to eight different places to get it, and half the time the equipment was not stored. If the equipment wasn't there, many said, "It's not worth the time to run down the hall and find the equipment. I just don't have time to do that." Doctors were forced to make an economic decision that put patients at risk. So one of the strategies we had was to get a line cart: a cart that stored all the equipment needed to comply with the checklist. We took eight steps down to one. We assigned someone to stock the cart and it dramatically improved compliance. A checklist is one thing, but if the supplies are not there, it doesn't do much good.
Another example is that infections can be cut by half when the skin is cleaned with chlorhexidine. Yet at the start of our program in Michigan, most central line kits did not have chlorhexidine, making it hard for clinicians to comply. The executives ensured they changed these kits so that they have chlorhexidine and now it is easy to comply.
Each hospital may have its own barriers, so we will [provide hospitals] train[ing] and tools to identify their own barriers, and they'll design solutions that fit them. They will share with each other what they are learning, [as] there may be a lot of overlap of barriers.
Q: How do you plan to use the $10 million in grant money?
PP: The way that it will be spent is some on data collection mechanisms, some providing support for clinicians leading these efforts, some for project coordination — to bring doctors together — and then some will support the research team to help design and evaluate if [the intervention] really worked and if it did work, why.
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Dr. Pronovost explains how this current project is taking a new approach to quality improvement.
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Q: What strategies will you use to reduce SSIs?Dr. Pronovost: The program is not just for SSIs, but other types of complications such as deep venous thrombosis, pulmonary complications and readmissions. We are focusing on all four of those. We are starting with colon surgery and will later expand to other types of surgery.
The approach that we're using is the concept of a clinical community. That concept is that amongst professional groups, quality improvement programs that are developed with rather than over clinicians are more likely to be wise, effective and locally implemented given the local context. Too often quality improvement programs are top down and they do not get implemented because clinicians had no role in creating it. It is really the concept of the community trusting clinicians to know what the risks are and empowering them to improve their own local risks. The community is supported by a technical core that provides support for measurement and improvement methods.
Within the community, there are three legs: measurement and feedback of performance data, implementation of best practices to prevent harm — for example, using a checklist or some intervention — and third, and perhaps most challenging, to improve culture and teamwork.
Q: How are the clinical communities organized?
PP: Communities are organized around states, health systems or interested hospitals. In this program, we partner with state hospital associations and the American College of Surgeons and then invite hospitals within [those associations] to participate. We have a series of conference calls or webinars to get out didactic material to clinicians. We then bring them all together for a face-to-face meeting for a day. It is very interactive; we talk about what we need to do to reduce harm, what barriers they think they're going to face, what successes others have had and what the training, measurement and outcome data will be. Then teams go back to the hospital and we have a series of biweekly or monthly coaching calls that involve the team from each hospital and a coach from the technical core — essentially it is peer coaching. We talk about what they're struggling with and they go back to implement changes.
Q: Why is the clinical community approach so important?
PP: If you look at quality improvement right now, most clinicians and nurses believe quality improvement is done to them rather than something they do. Most quality efforts are top down. But in part, the regulators have a strong voice because clinicians haven't stepped up to lead. In this work, when clinicians do it, it's much more effective. It's much more joyful because they really feel good about their work. It's going to take physician leadership.
Q: How can hospitals encourage physician leadership?
PP: One, hospitals can give physicians defined roles as quality and safety leaders in their institutions and ensure they have the time and skills to lead those roles. The average medical school doesn't prepare physicians with the tools they need to lead quality improvement efforts. For the most part physicians need formal training in the safety sciences. This should include training in designing, implementing and evaluating interventions; identifying and mitigating risks; improving teamwork and safety culture; and leading change. We are developing a safety certificate to provide this training for clinical leaders. Yet to really understand measurement and evaluation, physicians will likely need a public health degree. When the physicians have the right skills, the hospital can provide financial support for the time they devote to lead quality improvement efforts. If doctors spend their time doing quality, they're not generating income. It costs physicians money, yet it has enormous value. Without physician leadership, quality improvement efforts are unlikely to succeed. We need the hospital to provide support for clinicians, agree on the results they should achieve and hold them accountable.
Q: How do you plan to achieve a cultural change?
PP: We have this program called the comprehensive unit-based safety program, which is a unit-based team that tries to educate clinicians on the science of safety and the value of teamwork, provide tools to practice teamwork in a safe space and talk with peer leaders about role modeling good teamwork and culture change and through that, change the social norms.
The biggest culture change in all other work to reduce harms is whether the clinicians really believe that it's their job to reduce these harms and that they're able to do so. So often doctors say, "These infections just happen, there's nothing we can do about it. We operate on very, very sick patients." If they say that, it becomes a self-fulfilling prophecy. It is a big change to say, "These infections aren't inevitable, they're largely preventable, and I have the ability to help change that." When doctors believe that, they solve the rest of the problems. A large part of this program is to help physicians believe that harm is largely preventable and they can change their system to improve.
Q: How do you convince clinicians that they can make a difference in the rate of infections?
PP: We show them their own data about how often they use evidence-based practices, and work to make sure we are 100 percent on these. We ask them to tell stories on patients who have been harmed. Such stories do not quantify our improvement, but they are powerful in engaging clinicians about why this is so important.
Q: How will you recruit hospitals to participate in the project?
PP: We are going to recruit in two ways. The initial hospitals we are going to work with are hospitals that are already part of [the American College of Surgeons' National Surgical Quality Improvement Program] because we otherwise would not have baseline data to show things actually got better. The second year will be non-NSQIP hospitals. For both efforts, we are collaborating with the newly created Hospital Engagement Networks funded by CMS. We will present this program to HENS and send out invitations to state hospital association members. As you can imagine, those two ways will target different groups: The American College of Surgeons is more likely to get surgeons, and the HENS and state hospital association are more likely to get hospital executives.
What we've found is if you only get clinician buy-in, you often don't get enough support to do the work. On the other hand, if you only get executive buy-in, the program is rarely implemented at the bedside. There are so many examples where an executive signs up for a program and it is not implemented because clinicians often don't even know about it. You need to get both executive support and connect with practicing clinicians. One of the unique things about this program is that it's not either-or but about bringing those groups together. We try to bring together all stakeholders, hospital executives, clinicians, quality leaders, infection prevention staff and others. It takes a village to improve quality. We really have to work with everyone together to do this.
Q: What is your projected timeline for the initiative?
PP: The first year we will try 10 hospitals in 10 states. Then we will expand to the rest of the hospitals — importantly, the hospitals not originally doing the American College of Surgeons' NSQIP program. Probably in [six] months, we will begin implementing interventions. This study was funded prior to the launch of the HENS program by CMS. As such we will work closely with those efforts. We need to be sure that hospitals are implementing state-of-the-art safety programs that include valid measurement. What we've seen in other work, [such as with] pneumonia, is within three months we cut infections in half and by six months it is nearly eliminated. We think we can see, once we design the program over the next [six] months, that kind of rapid improvement.
Q: Will you implement a checklist as part of an intervention?
PP: We will certainly be using checklists. One of the things we realize is one of the main reasons patients don't get evidence-based practices is the ambiguity of who is supposed to do what, where, when and how. A checklist could be good to clarify behaviorally what to do. Even if people know, sometimes there are barriers, [such as] equipment. We will also identify local barriers to compliance with the checklist and then strategize to overcome those barriers. Simply handing clinicians a checklist will not likely be effective.
Q: How can equipment be a barrier to implementing evidence-based medicine?
PP: For example, in blood-stream infection work, we made a checklist, and the checklist required that doctors wear a cap and gown and mask. It sounds simple, but when we looked, that equipment was stored in eight different places. Doctors had to go to eight different places to get it, and half the time the equipment was not stored. If the equipment wasn't there, many said, "It's not worth the time to run down the hall and find the equipment. I just don't have time to do that." Doctors were forced to make an economic decision that put patients at risk. So one of the strategies we had was to get a line cart: a cart that stored all the equipment needed to comply with the checklist. We took eight steps down to one. We assigned someone to stock the cart and it dramatically improved compliance. A checklist is one thing, but if the supplies are not there, it doesn't do much good.
Another example is that infections can be cut by half when the skin is cleaned with chlorhexidine. Yet at the start of our program in Michigan, most central line kits did not have chlorhexidine, making it hard for clinicians to comply. The executives ensured they changed these kits so that they have chlorhexidine and now it is easy to comply.
Each hospital may have its own barriers, so we will [provide hospitals] train[ing] and tools to identify their own barriers, and they'll design solutions that fit them. They will share with each other what they are learning, [as] there may be a lot of overlap of barriers.
Q: How do you plan to use the $10 million in grant money?
PP: The way that it will be spent is some on data collection mechanisms, some providing support for clinicians leading these efforts, some for project coordination — to bring doctors together — and then some will support the research team to help design and evaluate if [the intervention] really worked and if it did work, why.
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